From boutique to basic: a call for standardised medical education in global health

Despite a substantial rise in global health interest and activities over the last decade, there has been surprisingly little emphasis on the medical education curriculum development necessary to inform and support these initiatives. Much of the global medical education literature to date has focused on the pros and cons of international student electives or descriptions of individual programmes.1,2 Few groups have considered how medical education must change to meet health care needs in a world where national and discipline-based boundaries are becoming increasingly meaningless. Few groups have considered how medical education must change to meet health needs in a world where national and discipline-based boundaries are becoming increasingly meaningless From entering medical students to G8 leaders, interest in global health is considerable and growing. In 2008, 28% of graduating US and Canadian medical students had participated in an international experience during medical school, reflecting a 270% increase since 1998.3 G8 governmental, foundation and other funding for global health activities more than doubled over roughly the same period, reaching US$17 bn in 2006.4 Diverse voices ranging from those of students to expert panel opinion have called for further expansion of global health care training and activities.5,6 Yet tremendous variation exists across medical schools in the type and amount of global health education students receive: offerings range from no training to multi-year programmes with didactic work and supervised field placements in low-income settings. Medical curricula vary in terms of the years in which global health materials are offered, whether courses are elective or mandatory, and the topics covered.7 If doctors are to have an ongoing role in addressing the most pressing factors affecting health while meeting the needs of today’s students and communities, medical education must incorporate global health topics. However, it is difficult at best to implement educational reform when little agreement exists on what constitutes appropriate global health care training for medical students. Although a few groups have proposed global health care curricula guidelines,8,9 a much more comprehensive consideration of global health care training by educators, accreditation bodies and universities is needed if medical schools are to fulfil their mandate to produce a workforce that is knowledgeable about current health issues. It is difficult to implement educational reform when little agreement exists on what constitutes appropriate global health care training for medical students The Institute of Medicine recently redefined ‘global health’ as ‘…the goal of improving health for all people by reducing avoidable diseases, disabilities, and deaths’.6 Global health does not refer solely to health problems that arise in impoverished areas of the world. Rather, it encompasses environmental, political, economic and social dynamics and diseases that affect individuals or communities across countries. Global health shares elements with public health, social accountability and international health. However, global health is distinguished from these disciplines by its focus on multinational problems and the need for cooperative solutions. Globalisation has substantially altered health and health care. People, produce and practices rapidly move around the world in ever-increasing volumes, facilitating disease spread. Health care professionals move to seek better conditions and patients travel for treatment. Whole populations are displaced by conflicts, and tourism in the most remote areas is burgeoning. New technologies mean that health information can be shared almost anywhere worldwide, and trade agreements may affect access to essential therapies. The socio-economic gap between the wealthy and the poor is widening, exacerbating disparities in health and access to health care. Climate change, urbanisation, gender inequalities, political instabilities and population growth are but a few of the many transnational factors that affect health and health care systems globally. Medical students trained in many current programmes are likely to be inadequately prepared to recognise and meet the health-related challenges created by an increasingly interdependent world. In today’s environment, it is imperative that all medical students are well-informed about how transnational and transdisciplinary factors and effective partnerships influence the health and well-being of patients and populations with whom they will work as doctors. Medical students trained in many current programmes are likely to be inadequately prepared to meet the health-related challenges created by an increasingly interdependent world If medical education is to be reformed to the extent required for students to be adequately trained in global health issues, a general consensus on what constitutes core competencies is needed. Individual groups of experts and organisations have begun identifying common themes,8 although much work remains to be done. The Global Health Education Consortium (GHEC) and the Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health have created a joint committee to develop global health core curriculum guidelines suitable for all medical students. Combining literature reviews with expert opinion, this committee is working to propose principles that can be publicly debated by medical educators, students and others, with the goal of guiding discussion towards consensus on what comprises appropriate global health training for medical students. Some argue that there is no room for global health in an already overcrowded medical education curriculum, that there is no need for all students to learn something about global health, and that global health is just one of a series of topics that are useful but not essential elements of a modern medical education. We feel these arguments fall short at all levels. There is a large and growing consensus that medical education needs to be reformed to address 21st century challenges.10 If we accept that medical education needs to be changed, then opportunities exist to revamp curriculum content. Programmes are repeatedly revised to reflect changes in scientific knowledge; these updates have and continue to occur without causing substantial differences in the overall length or structure of medical education. The issue is not about whether change can happen, but, rather, about what change is important enough to merit the effort. Is global health worth the effort? The over two-fold difference in life expectancies between countries, the potential for multinational epidemics such as influenza A H1N1, the global shortage and migration of health care workers and the worldwide movement of people, animals and food are just some examples of how global health issues touch most people’s health in some way. The issue is not about whether change can happen, but, rather, about what change is important enough to merit the effort Although 28% of recently graduated US and Canadian medical students participated in a global health experience, and 65% of US medical schools offered international elective opportunities, 43% of 2008 graduates felt that time devoted to global health was inadequate.3,11 Recently, the Bill and Melinda Gates Foundation awarded $4 m to plan a University of California system-wide School of Global Health,12 a Consortium of Universities for Global Health (CUGH) was established by leading North American academic institutions and the Institute of Medicine called on the US President to establish a White House Interagency Committee on Global Health within his first year in office.6 Over the past decade, tens of billions of dollars have been committed for global health activities through programmes such as the UN Millennium Development Goals, the Global Fund, and the US President’s Emergency Plan for AIDS Relief. Given this wide-scale interest and involvement by the public, governments, funders, universities and much of the medical community, it is hard to contend that global health is not among the forefront of current health issues. Although some may maintain that medical schools should not be required to teach global health to their students, the rationale for not doing so is unclear. Furthermore, given the rapid growth in global health interest at medical schools, those that fail to provide this training may find themselves relegated to the second tier. Despite the substantial growth in global health activities at medical schools, the haphazard nature of this growth has contributed to a highly variable amount and quality of training across different medical schools’ curricula.7 Although different pedagogic approaches can be beneficial and stimulate educational advances, the present lack of agreement on even basic elements of global health training has produced confusion. Developing a consensus on global health core competencies would be a first step to ensuring that all medical students receive appropriate and comparable global health training. In addition to the efforts begun by the GHEC, the AFMC Resource Group, CUGH and others, medical schools, professional educational organisations and accreditation bodies must become more actively engaged in understanding the minimum global health curricular components from which every medical student would benefit. Despite substantial growth in global health activities, the haphazard nature of this growth has contributed to a highly variable amount and quality of training The logistics concerning how to integrate global health training into overly packed medical curricula are daunting. However, medical schools throughout North America and Europe are developing models. As well as learning from these pioneers, schools should look to integrate global health issues into existing activities. Inner city clinics provide opportunities to teach culture competencies; classes on health resource utilisation present chances to contrast issues in high- and low-income regions. Core clerkships could include case studies that start with assumptions of limited diagnostic and therapeutic resources, helping students to understand how patient care may be provided under such circumstances and to think about when more resources are truly appropriate. At the same time, medical educators are encouraged to go above and beyond minimal recommendations and to develop advanced courses and training tracks for students interested in moving past basic knowledge or contemplating careers in global health. For students who undertake for-credit electives in low-resource settings away from their home institutions, medical schools need to ensure that sufficient supervision and learning objectives are in place. Defining core competencies represents one aspect of integrating global health into a modern medical education. Substantial challenges remain to be addressed before students can gain maximal benefit from global health training. Proposed knowledge and competency areas are likely to fall outside traditional departmental expertise, and faculty capable of working collaboratively in multidisciplinary fields will need to be developed and nurtured. Working in low-resource settings, especially internationally, creates logistic and ethical challenges to ensure that patient care and community resources are not compromised by student learning. These challenges will require medical schools to look beyond their traditional faculties for the necessary expertise in different fields. Medical schools in low-resource settings face even greater challenges, as local institutions produce a sizeable proportion of doctors for high-income countries.13 Addressing the brain drain requires more than curriculum reform, but the tactic of training more doctors in order to retain more is unlikely to be successful in the absence of more fundamental programmatic changes. Health has been defined as the ability to adapt.14 In a globalised world, medical education must adapt so that global health issues are essential components of all students’ learning, not just of an interested few. Without this adaptation, tomorrow’s doctors will be ill prepared to contend with the important changing forces influencing the health of patients and populations locally and globally.

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